Fat Shaming and Stigmatization: How Far Is Too Far?

Back in the late 1990s, Dr. Jerome P. Kassirer and Dr. Marcia Angell, both former editors-in-chief of The NewEngland Journal of Medicine, wrote an editorial in the journal about the “dark side to this national preoccupation” with weight loss, with failed attempts often leaving dieters blaming themselves for being undisciplined and self-indulgent, and feeling guilt and self-hatred.

In their column, Kassirer and Angell acknowledged that being overweight is indeed correlated with substantial medical morbidity but they also noted that obese people were often “criticized with impunity” by those “critics merely trying to help them.” They added: “Some doctors take part in this blurring of prejudice and altruism when they overstate the dangers of obesity and the redemptive powers of weight loss.”

They also speculated about whether being overweight was actually “a direct cause of those illnesses associated with it"—an idea as controversial then as now—but they added, “few would claim that becoming obese is consistent with optimal health.”

The World Health Organization calls obesity a “global epidemic.” About 1.5 billion adults worldwide are overweight and at least 500 million are obese as defined by body mass index (BMI), according to its most recent statistics. Some researchers predict that these numbers will increase substantially in the next 15 years. Ironically, even as our population has grown increasingly overweight, there is still considerable prejudice—and overt discrimination—against those who are weight-challenged, even among the professionals who work with this population. (See my previous blog, “We Hold Those Truths to be Self-Evident...”)

Herein lies the conundrum: Given the prejudice against the overweight and obese, what measures can or should be taken to stem the increasing obesity rates? In the name of public health, is it ever appropriate to stigmatize and shame people into losing weight?

Bioethicist Daniel Callahan, writing in the Hastings Center Report (2013), suggests that there is a place for so-called “fat shaming” to attempt to overcome this epidemic. He suggests three major strategies:

Childhood prevention programs (working through lunch programs, providing exercise opportunities in school and working through parents to discourage sedentary activities such as TV watching at home);

Most controversially, “social pressure on the overweight.” Callahan believes that “whether they recognize their own role or not, (the public) need to understand that obesity is a national problem, one that causes lethal disease.” His solution is social pressure “that does not lead to outright discrimination,” or what he calls “stigmatization lite.” He suggests a series of questions that could be asked to “nudge” people in the right direction: “If you are overweight or obese, are you pleased with the way you look?” for example, or, “Fair or not, do you know that many people look down upon those excessively overweight or obese?"

In a recent article in the journal Biothethics (2014), medical ethicist Christopher Mayes takes issue with Callahan. He explains that Callahan sees obesity not just as a clinical or personal issue but frames it as an “ethical issue with social and political consequences,” in which obese people not only harm themselves but others as well, because of their increased economic costs to society. The problem is that obesity is far more complicated than mere individual choice—there are social, cultural, environmental, and biological variables to consider as well.

In general, coercing individuals toward healthy behaviors is mostly ineffective and potentially harmful in that it may increase stigmatization.

Although sociologist Erving Goffman prominently wrote of stigma in the 1960s, there is still no widely accepted definition of the term. It is a cultural phenomenon that involves an us-vs.-them mentality, in which people distinguish and differentiate themselves from others seen as having undesirable characteristics. Stigma can be a potent source of social control that can result in both the loss of status in a community, as well as overt discrimination. Those stigmatized often resort to attempts at concealment. This may happen with a disease that is not always evident like HIV/AIDS or epilepsy. Concealment, though, is not an option for the overweight and obese.

Law professor Scott Burris, writing in the Journal of Law, Medicine, and Ethics (2002), raised the provocative question of whether there can ever be “good stigma,” as in the ongoing campaign against smoking, in which the activity was deliberately stigmatized and transformed “from being a glamorous activity” into “antisocial self-destruction.” The dangers of smoking were emphasized and smokers were stigmatized as the habit became socially unacceptable and even restricted in most public places.

Source: istock.com, VladSt, used with permission

Burris, however, writes that stigmatizing a person because of an addiction or disease is an “offensive” form of “social warfare” that does not belong in campaigns for public health. This was even addressed in the 1962 Eighth Amendment (“cruel and unusual punishment”) decision by the Supreme Court in Robinson vs. California regarding alcoholism. The Court found it "barbarous” to allow “sickness to be made a crime and [to permit] sick people to be punished for being sick.” But Burris does distinguish between actually stigmatizing people and labeling behaviors, such as smoking, unsafe sex, and overeating as “bad.” "Criticism and negative attitudes," he says, "are not stigma.”

Bottom line: There is no straightforward answer, in the name of public health, to the question of how paternalistic a society should be in its attempts to “protect” citizens from unhealthy behavior. But certainly shaming, prejudice, and discrimination have no place.

While I generally agree that heaping stigma onto people with undesirable behaviors is ineffective, I'm not sure it is even relevant in the case of changing our overweight/obesity prevalence. Comparing it to smoking is not accurate, either.

Asking whether stigma would be a useful pressure in getting people to change their weight presumes that we have good solutions for people to embark upon once they decide to make a change. The reality is that many factors act against a person trying to lose significant amounts of weight, including metabolic factors, and the very real inability to calorie restrict and cope with hunger/undereating for an extended period of time. This is one reason why the smoking comparison is inappropriate--smoking is a chemical addiction, and while it is extremely difficult to quit, smokers can experience less physical craving as they have more quit time under their belts. An overweight person who is calorie restricting will likely experience diminishing returns as time goes on, as well as fatigue from the experience of going hungry often--this tends to get worse with time.

Until there is a productive and reliable method for weight loss, I suggest you put the paternalistic and oversimplified question to bed of how to properly motivate those poor overweight people whom you must be assuming are simply not taking advantage of great remedies for their woeful situation. Please.

I think everyone agrees that being overweight CAN be detrimental to the health of the person. However, we must look beyond our current obsession with this issue. Truly it should not be fat vs thin in our society. And we must learn from history. So interesting when the use of amphetamines became stigmatized by the war on drugs that we started on the path of the war on obesity because few people realize that use of amphetamines to control weight especially in women was very common up until the early 1980's. I am not at all saying that use of amphetamines is a good idea for everyone but perhaps it did work for some people. In addition we are now a service industry society where jobs are full time with part time pay - high stress and low control. This certainly increases secretions of cortisol which in turn results in weight being deposited in the abdominal area. Good food is expensive and moreover when you buy fresh vegetables and fruits there is a large chance of the food spoiling before it is used. There are many areas where there is limited access to good and nutritious food. Children come home alone and must stay indoors because they live in neighborhoods where safety is an issue. Sports programs cost money and many low income communities have cut these programs or increased the fees. These are just a couple of areas of concern and there are many more including cultural components. Obesity is a public health problem that will not be addressed by use of stigmatization or other simplistic approaches. Really shame on anyone for believing such an approach should even be considered.

One of the biggest issues in this country is the American diet. We need to change our food system so that we produce more healthful foods instead of subsidizing corn, wheat, and soy, which are used in pretty much every processed food on the grocery store shelves. These foods are loaded with calories and we are constantly bombarded with advertisements for them.
Shaming and stigmatizing overweight or obese people is not going to fix the problem. Because of the complexity of the issue, there is no easy fix/cure. Here are a few suggestions though:
-overhaul of our current food system and subsidies of corn, wheat, and soy.
-Put pressure on advertising to limit ads targeted to children, promoting of unhealthy, empty calorie foods.
-Continued changes to our health care system that promote education and preventative medicine, instead of fixing the problems once they have already occurred.

I am sure that I am missing a few good points, but these are the three I feel are most important.

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